Consent to Charge Credit Debit HSA FSA Card Form

When I am not present to pay in person at the time of service by Breakthru Counseling &
Consulting, P. C. (BCC), please charge fees associated with the following BCC client:

Client Name

Date of Birth

This includes charges for missed sessions not canceled within One (1) Business day of the
appointment date.

Visa, MasterCard, AMEX, Discover are accepted by BCC as are Debit cards and most Health
Savings Account ( HSA) and Flexible Spending Account (FSA) cards.
The type of card I choose from those listed above to pay for psychological services rendered by
BCC is:

AMEX
Discover
MasterCard
Visa
My Debit Card
My HSA
My FSA

Name of Card Holder

Date of Birth of Card Holder

Billing Address on Card Street

City

State

ZIP

Phone number of Card Holder

If using a HSA or FSA Name of Employer of Card Holder 1

If using a HSA or FSA Name of Employer of Card Holder 2

If using a Debit card Name of Bank Debit card account is with

By my signature below, I authorize Breakthru Counseling & Consulting, P.C. (BCC) to charge
the card I chose above for psychological services rendered to the above-named BCC client. I
voluntarily choose and ask that my typed name on the signature line of this document legally
represent my electronic signature.

Card Holder Signature

Date